0001568166-16-000003.txt : 20160322 0001568166-16-000003.hdr.sgml : 20160322 20160322165109 ACCESSION NUMBER: 0001568166-16-000003 CONFORMED SUBMISSION TYPE: D/A PUBLIC DOCUMENT COUNT: 1 ITEM INFORMATION: 06b ITEM INFORMATION: Investment Company Act Section 3(c) ITEM INFORMATION: Section 3(c)(7) FILED AS OF DATE: 20160322 DATE AS OF CHANGE: 20160322 EFFECTIVENESS DATE: 20160322 FILER: COMPANY DATA: COMPANY CONFORMED NAME: Lombard International Life Assurance Co Separate Account VA104 CENTRAL INDEX KEY: 0001568166 IRS NUMBER: 520795747 STATE OF INCORPORATION: PA FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: D/A SEC ACT: 1933 Act SEC FILE NUMBER: 021-204495 FILM NUMBER: 161521518 BUSINESS ADDRESS: STREET 1: ONE LIBERTY PLACE STREET 2: 1650 MARKET STREET - 54TH FLOOR CITY: PHILADELPHIA STATE: PA ZIP: 19103 BUSINESS PHONE: 484-530-4800 MAIL ADDRESS: STREET 1: ONE LIBERTY PLACE STREET 2: 1650 MARKET STREET - 54TH FLOOR CITY: PHILADELPHIA STATE: PA ZIP: 19103 FORMER COMPANY: FORMER CONFORMED NAME: Philadelphia Financial Life Assurance Co Separate Account VA104 DATE OF NAME CHANGE: 20130129 D/A 1 primary_doc.xml X0707 D/A LIVE 0001568166 Lombard International Life Assurance Co Separate Account VA104 ONE LIBERTY PLACE 1650 MARKET STREET - 54TH FLOOR PHILADELPHIA PA PENNSYLVANIA 19103 484-530-4800 PENNSYLVANIA Philadelphia Financial Life Assurance Co Separate Account VA104 Other Insurance company separate account true 2013 LILAC Lombard International Life Assurance Company One Liberty Place 1650 Market Street - 54th Floor Philadelphia PA PENNSYLVANIA 19103 Promoter Issuer is an insurance company separate account authorized by PA insurance statute. Pooled Investment Fund Other Investment Fund false Decline to Disclose 06b 3C 3C.7 true 0001568166-15-000001 2013-10-09 true true true variable annuity contracts false 0 M Holdings Securities, Inc. 43285 Edward Houghton 735581 M Financial Plaza 1125 NW Couch St., Suite 900 Portland OR OREGON 97209 TX TEXAS false Summit Equities, Inc. 11039 Donald Gross 1913749 4 Campus Drive Parsippany NJ NEW JERSEY 07054 FL FLORIDA TX TEXAS false Winklevoss Insurance Agency, LLC 39081 Brian F. Burke 1024635 Two Greenwich Office Park 3rd Floor Greenwich CT CONNECTICUT 06831 FL FLORIDA false Summit Equities, Inc. 11039 Lawrence Bell 2227247 4 Campus Drive Parsipanny NJ NEW JERSEY 07054 FL FLORIDA false Indefinite 2126406 Indefinite false 2 23245 0 Issuer pays sales commissions which are equal to a percentage of premium received by the issuer. LILAC also pays sales commissions from its corporate resources. 0 false Lombard International Life Assurance Co Separate Account VA104 /s/ John F Reilly John F. Reilly Senior Vice President and Deputy General Counsel 2016-03-22